03 45636377 2026

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The document is a Uniform Consent to Service of Process form used by insurance entities to designate an agent for receiving legal notices and processes in various states. It includes sections for the applicant's information, certification by company officers, and resolutions authorizing the appointment of an attorney. The form ensures that legal actions can be initiated against the entity in designated jurisdictions, with binding effects on successors.

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Click ‘Get Form’ to open the 03 45636377 document in the editor.
Begin by entering the 'Applicant Name' at the top of the form. This is essential for identifying your application.
Fill in the 'NAIC No.' and 'FEIN' fields accurately, as these numbers are crucial for regulatory purposes.
In the 'Uniform Consent to Service of Process' section, select either 'Original Designation' or 'Amended Designation' based on your needs.
Complete the 'Insurer Name', 'Previous Name', and 'Home Office Address' sections with precise information to ensure compliance.
For each state where you appoint a designated agent, place an 'X' next to their names in Exhibit A. This step is vital for legal notifications.
Ensure that one of the officers listed signs and dates the certification section at the bottom of the form, confirming their authority to execute this document.

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